Abstract

The recovery phase of an infectious disease emergency is rarely a linear process, but it represents an opportunity to ‘build back better’. In this chapter, we focus on efforts to restore a community’s health system, though broadly understood, recovery also refers to restoring (and improving) all emergency-affected systems and structures. Restoration of health system functions needs to be done while still controlling the disease, addressing the inequalities and disproportionate impacts that the emergency has revealed, and beginning the process of effective reviews that will feedback in to future preparedness efforts.

Introduction

The recovery phase of the emergency cycle, as defined by the World Health Organization (WHO), involves “restoring or improving … livelihoods and health, as well as economic, physical, social, cultural, and environmental assets, systems, and activities in an emergency-affected community or society, aligning with the principles of sustainable development and ‘build back better’” [1].

The study of how societies can recover effectively from infectious disease emergencies receives relatively little attention, and there is a significant risk that national and multinational organisations in the throes of a health emergency may overlook this key phase of the emergency management cycle. Progression from response to recovery and through the recovery phase is unlikely to be linear and unidirectional. Further outbreaks and emergencies during recovery can complicate the situation, while developments in our knowledge and management of the infectious disease can change our understanding of what the recovery phase should look like.

In this chapter, we focus on one crucial aspect of the broad scope of recovery as defined by the WHO: the recovery of health systems. To do this, we have developed a framework consisting of four broad objectives:

• resuming the provision of health services

• maintaining control of the infectious disease even as urgency recedes

• addressing inequalities and the needs of disproportionately affected groups

• undertaking effective reviews that contribute to learning and future preparedness

These four objectives are actualised by three principles, which should be applied across all objectives and underlie policy and operational considerations during recovery:

• capitalise on opportunities to improve health

• always consider local contexts and their implications on policy goals and effectiveness

• support the well-being of health workers

Resumption of health service provision

The resumption of health service provision during recovery is crucial for the restoration and improvement of health and well-being. This is related to, but distinct from, the maintenance of essential health services during the response phase (See Chapter 23, Essential services). Approaches to aid the resumption of health service provision fall under several broad areas.

Reducing the risk of transmission in health facilities

The risk of further disease transmission in health facilities is likely elevated in the recovery period as preventive measures are lifted, posing a potential impediment for a return to ‘business as usual’. Outbreaks of infectious diseases distinct from the cause of the primary emergency can also occur, and indeed may be more likely due to the stress placed upon health, social and economic systems. Further infectious disease outbreaks can severely impede health service provision as resources have to be redirected and healthcare staff may themselves be affected. Patients are also less likely to attend health centres if there is a perceived risk of infection.

The risk of transmission in health facilities may need to be re-addressed for the recovery phase, including through the modification of physical facilities. Walls, screens and doors can be installed to delineate “high-risk” and “low-risk” areas, with buffer zones for activities such as the removal of personal protective equipment (PPE), and areas used by healthcare workers (HCWs) can be separated from those used by patients and other visitors. Waiting rooms can be reconfigured or expanded, and processes such as patient registration or checking out can also be conducted virtually to facilitate physical distancing [2][3]. Another possible approach is to do away entirely with waiting rooms, either by scheduling patients to arrive precisely on time for their appointments or encouraging them to wait in cars if suitable parking facilities are available. Improving the ventilation of high-risk areas should be considered if airborne transmission of the pathogen is suspected. This can involve setting up negative pressure rooms, but simpler approaches such as carrying out aerosol-generating procedures near windows may also be helpful in resource and time-constrained settings [4]. Some of these interventions may already have been carried out in the response phase. An assessment of their effectiveness, including any adverse impacts on service capacity, quality or equity, should be undertaken in response to actions taken during recovery. If planned and executed well, changes made during recovery can lay the foundation for preparedness for the next emergency.

Workforce management and training

In recovery, health systems must address backlogs of elective clinical work even while dealing with long-term health sequelae of the infectious disease outbreak. It is crucial to ensure that all HCWs are equipped with the skills, knowledge, and support required for the resumption of health services during the recovery phase. Given the challenges of recovery, it is not too late for training in infection prevention and control measures, epidemiological data collection, and skills required to address community-specific priorities [4][5].

Extending operating hours or running weekend clinics, theatres, and radiology and pathology services can also directly increase the number of patients served [6][7][8], although human resources and funding constraints may limit the practicality of this in the longer term. In addition, health leaders and administrators should actively review performance and make contingencies for surge capacity to deal with further outbreaks or other emergencies.

Engagement with communities, healthcare staff, and other stakeholders

Engagement with local communities and other national and international actors is important for ensuring that recovery plans adequately address local needs and priorities, which may change over time. Furthermore, reassuring communities about infection control measures implemented in hospitals and other health centres is crucial for overcoming hesitancy in seeking medical care. Regular and clear communication between healthcare staff is also required to convey changes in processes and ensure that logistical support meets demand [6].

Improvement of supply chains and health system logistics

Recovery is a highly dynamic phase which often involves repeated local infectious disease outbreaks and associated social and economic challenges. The emergency may have revealed weaknesses in infrastructure and the inadequacy of logistical planning and networks. While it is difficult to build infrastructure like bridges, roads, and storage facilities, or to improve cold chains for distribution of vaccines and medication in this phase, such improvements may nonetheless be needed to enable regular health service provision. Because of the risk of ongoing outbreak-related disruption in the recovery phase, such projects should ideally be carried out as part of preparedness measures in the pre-outbreak period, though this is often impeded by financial costs and limitations in understanding the weaknesses of health system logistics [9]. Supplies of certain medications, PPE, and blood for transfusions are also likely to be constrained during and after an infectious disease emergency, and this may impede the resumption of health services [10].

Prioritisation of services and research activity

Higher-level actors should facilitate coordinated initiatives to improve health service provision in particular areas of concern, while allowing local bodies the flexibility to address local needs. Modelling and epidemiological studies can reveal services for which rapid resumption is critical for reducing mortality [10][13]. Examples of areas which regional and national health systems have chosen to focus on during recovery include cancer diagnosis and care, catching up with childhood vaccinations, prevention of malnutrition, and management of chronic diseases. Research priorities should also be reviewed to re-evaluate underlying cost-benefit assumptions which may have changed over the course of the emergency, and to free up resources for more pertinent needs where appropriate. Considerations relevant to research activity prioritisation include the severity of the associated disease, patient needs, demands on human and financial resources, and the potential for reducing in-person visits to health centres to decrease the risk of infectious disease transmission [6].

Maintaining control of the infectious disease

Although infectious disease emergencies would ideally conclude with complete eradication of the disease in question, this is historically a rare outcome and unrealistic in most circumstances. It would thus be unwise to assume that vaccination or other measures will be successful in fully eradicating any novel infectious disease. There is thus a need for health leaders and policymakers to plan for dealing with the disease in the long term. This is best done with a full understanding of the socio-economic impact of public health measures on the community, and the community’s capacity to implement and adhere to public health policies and other measures.

Transmission control measures should be locally stratified in recovery

The impact and utility of community transmission control measures including vaccination, testing, school closures, isolation requirements, and restrictions on public gatherings and business and social activities have been discussed elsewhere in this book. Some of these measures may maintain a degree of usefulness at preventing and controlling infectious disease transmission sufficient to justify their use in the recovery phase, although this should be reassessed based on pathogen and population factors such as the prevalence of vaccination or infection-derived immunity.

The substantial financial and human costs involved in these transmission control measures mean that they should be relaxed to a baseline level in the recovery phase and dynamically stepped up or down to control local outbreaks where appropriate [14]. Risk-based stratification of transmission control measures across different communities is important for supporting sustainable and dynamic infectious disease control and preventing potential spillover events, whilst facilitating a timely return towards a ‘new normal’ for as many people as possible [15].

Data collection and monitoring capacities required during recovery

Monitoring pathogen transmission and evolution is important for informing decisions about public health measures and resource allocation but plays a somewhat different role during response and recovery. The focus of testing in the recovery phase, from a health systems perspective, shifts from diagnosis for clinical and public health purposes to monitoring community prevalence, particularly if the availability of vaccines or effective treatments reduces the utility of early diagnosis. Such studies can also improve our understanding of symptoms associated with infection and the proportions of symptomatic and asymptomatic infections, which may vary over time based on pathogen and host factors [16]. It is important to ensure that accessibility barriers, such as testing costs, do not limit the ability to maintain surveillance activities during the recovery phase.

Genomic sequencing (See Chapter 21, Genomics) is another important tool for surveillance of pathogens and is of use in the recovery phase for detecting emerging variants which may be more transmissible or virulent, or more able to escape population-level immunity [17]. However, the SARS-CoV-2 pandemic revealed that marked regional differences in sequencing availability exist along economic lines. Furthermore, much sequencing data is not shared on publicly available repositories [18]. These issues must be addressed to fully realise the potential of genomic surveillance for detecting and tracking emerging variants globally. Other methods of disease surveillance include sentinel surveillance, wastewater testing, and event-based and indicator-based surveillance. Their relative appropriateness in the recovery phase is dependent on factors including prevalence, degree of health-seeking behaviour, quality of data-collection systems, and cost.

Monitoring the state and capacity of health systems is just as important as monitoring the evolution and spread of pathogens. Reliable and up-to-date data on hospitalisations, deaths, intensive therapy unit occupancy rates, supplies of critical medications, and workforce capacity and capabilities are necessary for health leaders and policymakers to make informed decisions. Equally critical will be planned and proactive application of behavioural science approaches to ensure a good understanding of evolving community attitudes and perceptions. 

Addressing inequalities

The burden of infectious diseases has consistently fallen heaviest upon underprivileged communities. Greater pre-existing inequality has been associated with increased mortality, both among deprived communities and at the national level between countries [19][20][21]. Contributing factors include poorer access to and provision of health care, pre-existing health, economic, and educational disparities, and less extensive social support networks. Public health and social measures adopted to suppress disease transmission during the response phase can also disproportionately affect certain groups of people and widen existing inequalities. School closures, for example, have a greater impact on disadvantaged children for reasons that may include interruptions in provision of free school meals, reduced opportunities for safeguarding interventions, and differences in accessibility of online learning resources and private tuition [20][22]. Other groups that may be disproportionately affected over the course of an infectious disease outbreak include ethnic minorities, people with disabilities, the elderly, the homeless, and migrants. Elderly care homes, refugee camps, slums, crowded factories, prisons, and migrant centres and dormitories are all possible settings where transmission may be elevated.

It is important to bear these considerations in mind throughout all stages of the emergency cycle, but this is especially important in the recovery phase where the relatively stable situation allows data-driven assessments to be made of inequalities arising from the outbreak and response measures. An effective emergency response system should include mechanisms for collating information about the impact of the emergency on marginalised and underserved groups in the population. Analysis of such information should inform areas of focus and prioritisation of recovery objectives.

Prioritisation between different areas of recovery

The recovery phase is certainly a key period for seeking to correct inequalities and mitigate the effects of the outbreak on disadvantaged groups. However, the objectives of recovery detailed thus far all require large-scale, resource-intensive approaches for them to be comprehensively addressed. The question of prioritisation between competing health, economic, and social priorities is fundamentally one for governments to address. However, it would be inaccurate to see goals in these areas as mutually exclusive. Improvements in the health of communities can contribute significantly to economic and social recovery, and vice versa. Health policymakers should closely interact with leaders from other fields to develop interventions and reforms that can achieve broad gains across different areas as part of a “health in all policies” approach [23].

Undertaking effective reviews

Reviews of health system preparedness and response to infectious disease emergencies are by no means exclusive to the recovery phase. However, the recovery phase is an opportune period for organisations to examine their preparations for and response to emergencies, and to apply lessons learnt with the goal of improving preparedness and building resilience for the future. Such reviews should not be limited to the health sector as infectious disease emergencies impact all aspects of social and economic development, and preparedness and response efforts are also influenced by political factors. National reviews should be conducted and fully owned by governments, even if they are supported by the WHO or other partners, and should be undertaken on a whole-of-government and whole-of-society basis. Whether conducted at national, other governmental levels, or by non-governmental organisations, leaders need to own the review process, agree with the methodology, make it as transparent as possible, and provide appropriate resources. Ownership and full engagement from the top are necessary if reviews are to accurately identify learning points and lead to real improvements.

Types of reviews

Multiple forms of reviews are applicable to health emergencies. After-action reviews are mainly conducted during recovery and examine actions taken during and prior to the response phase to identify best practice, areas for improvement, and lessons learnt [26]. These are distinct from intra-action reviews carried out during the response phase, which focus more on applying lessons learnt to improve the contemporaneous emergency response. Issues and areas for improvement uncovered by intra-action reviews can also inform the planning and implementation of recovery efforts. The WHO produces guidance on how to undertake these types of reviews, and itself regularly conducts joint operational reviews [27]. These operational reviews are distinguishable from other types of reviews in that they are WHO-led, typically occur during or towards the end of the response phase, and seek to ensure that the efforts of the WHO at all levels are effectively aligned with national ministries of health in achieving objectives as planned.

Reviews may be conducted informally, for example as part of a debrief session, or formally with a more structured process usually overseen by someone outside the team directly involved in the action. The precise manner in which an after-action review is conducted can be varied to suit the context, resources, and time available. The general aim is to facilitate the exchange of observations, ideas, feedback, and other data, with a focus on identifying lessons and proposing recommendations for future practice. Options for accomplishing this include interviews, focus group discussions, surveys, and workshops, which should be conducted as soon as possible after the event or outbreak [27].

Informing future preparedness

Learning should occur at all levels, from individuals to organisations, nationally and globally. Meaningful engagement with the review process, transparency, and effective follow-up are key components of effective reviews that can contribute to learning across multiple levels.

Engagement with the review process is greatly supported by fostering a ‘no-blame’ culture, as people may refrain from engaging candidly if they feel it may result in them suffering personal repercussions. After-action reviews serve to identify lessons and ways to improve, and should not be an evaluation of any individual’s performance nor a means of apportioning blame [27]. This also helps ensure that the results of reviews – particularly formal ones – are shared widely to spread learning and increase public confidence. A ‘no-blame’ approach has been successfully used to promote organisational learning at the sector level in the aviation industry [28], and is also conducive to learning because incidents (near-miss or otherwise) linked to human error often have underlying system failures [29].

Reviews cannot produce full solutions to the complex issues faced in outbreak preparedness and response, and reviewers should not aim for them to do so. Rather, reviews should seek to provide recommendations for improvements which, if appropriately translated into policy, can serve as the basis for further evaluation and learning. In this way, reviews contribute to organisational learning through an incremental and iterative process. Several practices have been suggested to improve the application of lessons learnt from reviews. Reviews should have clearly defined objectives, frameworks, guidelines, and tools underlying the process to facilitate the generation of clear recommendations for improvement and follow-up actions [25]. Follow-up actions typically involve the direct implementation of a recommendation or the monitoring and oversight of its implementation, the latter being more likely if broad changes at the organisational level and senior leadership decision-making is required. In such cases, the reviewing group or another body should be empowered with sufficient resources to monitor the implementation of recommendations of the review. Subsequent communication and implementation of recommendations may be aided by identifying a point of contact and timeframes for feedback for each follow-up action [30].

The early part of the recovery phase is a key period for after-action reviews to be initiated and conducted. These should be conducted at multiple levels, openly and honestly, and with appropriate follow-up measures to effectively contribute to learning and long-term preparedness.

Principles for recovery

The planning and execution of policies aimed at achieving any of the four broad objectives for recovery of health systems should be guided by several key principles to ensure that recovery is effective and provides health systems with enhanced resilience for future stresses.

Capitalising on opportunities to improve health

Technological developments can provide new, more effective means of achieving desired outcomes in recovery and beyond. For example, technological advancements can allow for mobile applications and software to aid in the collection and monitoring of infectious disease-related epidemiological data [9]. Technological developments may also provide much-needed tools to collect, integrate, and track data on the longer-term effects of an outbreak, such as information on developmental delays in children [31]. In addition, advances in telehealth may offer cost-effective means of addressing health service backlogs while reducing the risk of transmission in crowded health facilities, although this may be more limited in rural or resource-constrained settings.

The recovery phase is a key period for considering how technological advancements should be used to improve health in the long term. Doing this effectively requires an understanding that recovery involves societies moving towards a ‘new normal’ which may look quite different from the pre-emergency situation, with ample room to accommodate new methods and platforms. However, underlying evidence must be carefully evaluated from the outset, with a particular focus on assessing the potential of new processes to exacerbate inequalities in healthcare and the suitability of such processes for particular groups of patients.

Not all opportunities to improve health in the wake of an infectious disease emergency are technology related. Disruption to everyday life and habits during outbreaks can open the door to interventions that promote lasting improvements in health, such as by discouraging the use of carbon-emitting motor vehicles in cities and adjusting policies to support environmental improvements, as proposed by the WHO in the aftermath of the SARS-CoV-2 pandemic [32]. Large-scale vaccination campaigns can also be ‘piggybacked’ on to reach underserved members of the community, while greater health literacy and community involvement can be leveraged to address other health issues such as malnutrition and diabetes [33].

Consideration of local contexts

In recovery, as in the response phase, consideration of local social, political, economic, and cultural contexts is important to ensure that policies are effective at addressing the needs of local communities. This requires close engagement with local communities and stakeholders, as well as the understanding that careful consideration is required before the evidential bases for policies established by research in one country or community are extrapolated to other communities.

Important points for health leaders and policymakers to consider during recovery include the prevalence of misinformation, levels of public trust in health-related institutions, and attitudes towards disease survivors and their families. A deeper understanding of the nuanced social context can often help to address problems during recovery. For example, community-based care for orphans following an outbreak may be impeded by resource constraints, stigmatisation, and discrimination, or all of the above [34]. A focused approach tailored to local contexts is thus required.

Support for the welfare and well-being of health and social care workers

Prioritisation of the welfare and well-being of health and social care workers, including both formal employees and volunteers, should be a feature across all policies adopted as part of emergency response and recovery. Factors which contribute to this include good workforce planning, fair remuneration, and flexibility in terms of working arrangements [6]. The psychosocial and mental well-being of health and social care workers can be supported in greater detail (See Chapter 31, Mental health).

Conclusion

Given the immediate stresses of the emergency response, the recovery phase of the emergency cycle is often overlooked by both researchers and policymakers. The framework for recovery outlined in this chapter will hopefully be helpful when considering issues in this highly complex field. Most of the practical points raised in this chapter have been presented from the perspective of clinicians and public health leaders. Of course, much more can be written about recovery from economic, social, cultural, and environmental perspectives. Many of the underlying considerations of our framework, such as the need to address inequalities and conduct reviews that contribute to learning, are very relevant to non-health organisations as well. Indeed, a coherent and coordinated multi-sectoral and multi-disciplinary approach is required to achieve an effective recovery that will stand societies in good stead for the future.

Contributor biographies

Jen O. Lim is a medical student at the University of Cambridge with a special interest in eye conditions and genetic diseases. He is the recipient of several academic awards and has been involved in widening access and cancer awareness efforts in his university.

Ebere Okereke is recognised for her expertise shaping public health policy, designing strategic frameworks, and executing complex health programs. Her work primarily focuses on global health security, health system strengthening, and the cultivation of effective leadership in the field. Most recently, Dr Ebere was the CEO of the Africa Public Health Foundation. Previous roles include Lead Consultant in Public Health England's IHR Strengthening Programme; Senior Adviser to the Tony Blair Institute for Global Change; honorary Senior Adviser to the Director of Africa CDC, and co-lead for the Africa Union’s Partnerships for African Vaccines Manufacturing. She is a Fellow of the UK Faculty of Public Health and an Associate Fellow at Chatham House. A graduate of the University of Nigeria College of Medicine, she holds a Masters of Science degree from Newcastle University and an honorary Doctor of Science degree from Liverpool School of Tropical Medicine .

Magda Robalo is the President and co-founder of The Institute for Global Health and Development (IGHD). She is a public health physician and infectious disease expert, whose career spans over 30 years in the global health ecosystem. She held senior leadership positions at the domestic and international levels in various professional settings, working with Government, multilateral, and civil society organizations. She has a track record in promoting gender equality and equitable access to quality health care, social justice, ethics, and accountability. She has worked on a broad range of public health issues, and actively works on gender equality, ethics, and governance. She spearheaded successful initiatives as former Minister of Health, High Commissioner for the COVID-19 response in Guinea-Bissau, WHO Representative and WHO Director of Communicable Diseases and the Global Managing Director of Women in Global Health. She serves on several Boards and Councils. Dr Magda Robalo is a medical doctor (Universidade do Porto, Portugal) with a Postgraduate Certificate in Public Health and Tropical Medicine (Universidade Nova, Portugal) and a Master of Sciences degree in Epidemiology (Université Laval, Canada).

Renu Bindra is Deputy Director Public Health Clinical Response at the UK Health Security Agency. She is an experienced public health physician with significant expertise in all hazards incident management and in policy, strategy and service development. She has extensive infectious disease outbreak management experience and was the Head of COVID Advice and Guidance for Public Health England at the height of the pandemic, leading across government on the coordination of evidence and advice to inform policy on all aspects of testing, tracing and isolation. She previously established and chaired a regional TB Control Board, overseeing a comprehensive programme of regional TB control activities, as well as leading national work on MDR-TB. Renu has a strong interest in healthcare leadership and has received the NHS Leadership Academy Award in Executive Healthcare Leadership.